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<meta name="description" content="接下来是病例了，就不一一记了，记下收获和细节吧。下颌阻生牙探诊分离牙龈要彻底，并按顺序分离。远中牙龈切口暴露下8远中边缘嵴即可。缝针不宜过密过紧，便于引流、减轻肿胀。(牙根靠近下颌管时)使用牙挺拔牙时，尽量使牙齿向冠方移动。选择从小号到大号的牙挺使用顺序，逐渐加力使牙齿松动，尽量避免力量过大导致的断根。如果常规牙挺插挺困难，建议使用微创牙挺增隙深度约5mm，再插普通牙挺拔除患牙。远中切口牙略偏颊侧">
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<meta property="og:description" content="接下来是病例了，就不一一记了，记下收获和细节吧。下颌阻生牙探诊分离牙龈要彻底，并按顺序分离。远中牙龈切口暴露下8远中边缘嵴即可。缝针不宜过密过紧，便于引流、减轻肿胀。(牙根靠近下颌管时)使用牙挺拔牙时，尽量使牙齿向冠方移动。选择从小号到大号的牙挺使用顺序，逐渐加力使牙齿松动，尽量避免力量过大导致的断根。如果常规牙挺插挺困难，建议使用微创牙挺增隙深度约5mm，再插普通牙挺拔除患牙。远中切口牙略偏颊侧">
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        <p>接下来是病例了，就不一一记了，记下收获和细节吧。<br>下颌阻生牙<br>探诊分离牙龈要彻底，并按顺序分离。<br>远中牙龈切口暴露下8远中边缘嵴即可。<br>缝针不宜过密过紧，便于引流、减轻肿胀。<br>(牙根靠近下颌管时)使用牙挺拔牙时，尽量使牙齿向冠方移动。<br>选择从小号到大号的牙挺使用顺序，逐渐加力使牙齿松动，尽量避免力量过大导致的断根。<br>如果常规牙挺插挺困难，建议使用微创牙挺增隙深度约5mm，再插普通牙挺拔除患牙。<br>远中切口牙略偏颊侧。<br>切开一定切透黏骨膜。<br>垂直位常规在近中、颊侧两个部位插挺。<br>缝合不宜过紧，防止肿胀明显。<br>急性期拔牙，有利于建立引流，缩短疗程和减少并发症的发生。急性期拔牙后，应密切观察病人，继续加强抗感染措施，及时处理发生的问题。<br>口外局部麻醉不要将麻药注射进脓腔内。<br>牙龈覆盖牙冠牙合面1./2，仅做切开，不做缝合。<br>一般在颊侧和近中插挺，采用推法、挺法、楔法、撬法相结合。<br>建议初学者，先从垂直高位、融合根做起，逐步过渡到中位阻生智齿的拔除，积累经验，循序渐进。<br>切口小，翻小瓣，可以大大降低术后肿胀反应。建议先做远中切口，如果可以充分暴露牙冠，就无须增加颊侧的垂直附加切口。<br>建议分牙间隙在2mm左右比较适宜插牙挺，过窄需反复磨除部分牙体组织，为插挺创造条件。也可以将牙冠磨除至即将截断，用牙挺撬开。<br>对于高位阻生的牙齿，建议先分牙，后分离牙龈。（为什么？防止牙龈出血分牙视线不清楚？）<br>近中阻生的融合根采用斜分牙冠，近中阻生的分叉根采用纵分牙冠和牙根。<br>注意钻针磨除的深度和方向，防止损伤牙槽骨和邻牙。<br>颊侧切口不要超过前庭沟，防止术后肿胀明显。<br>尽量多分牙，少去骨。<br>（近中阻生分叉根）分牙注意深度及舌侧骨板，从颊面正中开始分牙，始终保持与牙长轴一致，才能顺利地从根分叉处把患牙一分为二。（偏了就只有掏根了。）<br>分牙时高度专注切割牙齿过程中的感觉，第一次落空感是达髓腔，第二次落空感就是磨穿根分叉。<br>角形切口建议远中缝合两针，近中颊侧切口缝合一针。一定要对位整齐缝合，不宜太紧或太松。<br>分牙注意切割深度和方向（水平阻生，齐颈部分冠，然后T字形分牙，最后取出牙根。）<br>丁字挺的正确使用：放在纵分牙冠的间隙里，先出舌侧牙冠，再以颊侧骨板为支点，取出颊侧牙冠部分。<br>去骨暴露最大周径即可。<br>挖匙清理牙槽窝一定彻底去除牙碎片、骨碎片及牙囊。可术后拍片。<br>由于快机冷却水无法完全无菌，建议清理完牙槽窝后，使用20ml的生理盐水冲洗牙槽窝3次。<br>分牙注意深度，防止损伤下牙槽神经。<br>牙挺在施力过程中，使牙根尽量向冠方移动，而不是向根方移动。<br>下牙槽神经阻滞麻醉时应旋转进针，可以保证针头方向不偏斜。<br>应用笑气之前，应了解患者是否适合使用笑气，有的患者使用笑气有窒息的感觉，则不适合使用。<br>分牙注意深度，有落空感即可，然后牙挺放入分牙间隙，旋转即可把牙冠分成近远中两部分。<br>7为修复体时，术前检查7修复体下方有无继发龋、有无桩核、是否是种植体等等。<br>术前告知可能损伤前面的修复体，导致修复体需要重新制作。<br>7为种植体，需要片切8，保证7种植牙在8拔除过程中不受力。<br>使用牙钳拔除8时，注意摇动力一定要缓慢、反复、渐进加力。<br>微创挺增隙一定要深达牙根长度的2/3。<br>7缺失要做种植，8阻生时，最好先拔除8再做种植。<br>上颌阻生牙<br>牙齿脱位时，持针器夹持要稳当，防止掉落在口腔咽部，导致误吞。<br>患者半开口，使颊部松弛而便于拉开，暴露前庭沟，利于注射麻药和手术操作。<br>上颌智齿拔除主要受空间限制，视野较差，不建议涡轮钻去骨。<br>半闭嘴处理拔牙创并缝合。<br>因上颌结节骨质疏松，不建议分牙，直接挺比较合适。（根分叉大，挺不动的怎么办？）<br>术前的临床检查和CBCT影像分析最为重要，防止误诊误拔。<br>半闭口做颊侧浸润麻醉，大张口做腭侧浸润麻醉。<br>近中插挺，使用推力和挺力相结合，使28向远中、颊侧脱位。<br>上8与上颌窦关系密切，若穿孔，缺损处填塞胶原蛋白海绵，缝合。<br>（其它牙位埋伏牙的拔除略过了，反正我遇到了是转诊的。）<br>其它牙位<br>（上颌前牙）<br>分离牙龈要彻底，四周都要分离开，防止拔牙过程中撕裂牙龈。<br>牙钳一定和牙长轴保持一致，夹住牙颈部，并钳喙进入龈沟内，抵住牙槽嵴顶。<br>可以使用旋转力的牙齿包括上颌的前牙和下颌的尖牙，下颌第一、二前磨牙，其他牙不建议使用旋转力。<br>为了给即刻种植创造条件，建议片切，去除与相邻两颗牙的接触点。<br>上前牙唇侧骨壁完整性的保护对即刻种植尤为重要，注意术中使用微创挺的部位，方向。<br>断根根尖部分仍采用近中、远中、腭侧增隙，让牙根自动往牙槽嵴方向浮出。<br>错位牙不在牙弓上，传统的棉球压迫止血不便应用，建议使用止血敷料填塞，协助止血。<br>（错位多生牙）<br>使用微创挺来挺松患牙，尽量让邻牙不受力，可以片切使多生牙与相邻两个邻牙失去接触，这样再插挺时，邻牙真正的不受力。<br>（上后牙残冠）<br>颊侧、腭侧均采用浸润麻醉为好。<br>分牙从髓腔底部中央开始，始终与牙长轴一致。<br>采取近远中分成颊腭侧两部分，然后颊侧再颊舌向分成近中颊根和远中颊根。<br>分牙注意落空感，不要磨除过深，损伤牙槽间隔，导致牙槽嵴高度不足。<br>上颌后牙拔除操作视野受限，建议用口镜反光定期检查分牙情况。防止分牙分偏，导致拔牙愈加困难。<br>(下后牙根管治疗后拔除）<br>分牙应在牙合面正中央为基准，加长车针与牙长轴方向始终保持一致，不然会切割偏斜，牙根无法分开的情况发生，导致拔牙困难。<br>术中分牙注意两次落空感，第一次证明达到髓腔，第二次落空穿过根分叉。<br>注意磨除深度，不要过度磨除牙槽间隔，为后期种种保留最大限度的骨量。<br>（残冠，残根）<br>长期残根导致牙龈及根尖均有炎症，建议搔刮牙槽窝底及四周，按顺序搔刮，不要遗漏，彻底刮除肉芽组织。然后复位，压迫止血。<br>断面位于龈下的牙根拔除，最好建议用电刀或者手术刀切除覆盖在牙根上的牙龈组织，暴露出根面与牙槽骨之间的间隙为好，不建议视野不清的情况下拔牙根。<br>不建议在腭侧做垂直附加切口，垂直切口虽然可以充分暴露视野，便于操作，但容易损伤腭大动脉，出血较多，缝合也比较困难。<br>(那些门诊手术先pass了）<br>（拔牙术中术后并发症）<br>去根方法：<br>①牙挺取根法<br>适用于牙颈部以下，低于牙槽窝：<br>断根&gt;根长1/2直、弯挺，从高侧开始。<br>断根&lt;根长1/2根尖挺，从高侧开始。<br>注意，牙挺必须在牙槽骨和牙根之间。<br>②分根取根法<br>适用于多根牙，断根在根分叉以上，先分根再分别取出，上颌第一磨牙最常用也适用于阻生多根牙取根。<br>断根留置条件：<br>①断根小于3-4mm。<br>②根尖周组织无感染或其它病理改变。<br>③手术视野内看不到断根。<br>④取出断根有可能导致上颌窦或者下牙槽神经损伤。<br>⑤不能控制的拔牙术区出血<br>⑥拔牙时间长、病人感觉不适、不能继续承受拔牙。</p>
<p>我发文章的三个地方，欢迎大家在朋友圈等地方分享，欢迎点“在看”。<br>我的个人博客地址：<a href="https://zwdnet.github.io/">https://zwdnet.github.io</a><br>我的CSDN博客地址：<a target="_blank" rel="noopener" href="https://blog.csdn.net/zwdnet">https://blog.csdn.net/zwdnet</a><br>我的微信个人订阅号：赵瑜敏的口腔医学学习园地</p>
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